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Wednesday, May 30, 2012

Redefining Hope

BY ROY B. SESSIONS, MD

Professor of Otolaryngology Head and Neck Surgery

The Medical University of South Carolina

Most of us who treat cancer patients understand that in order to be effective in managing all of their needs, there must be an emotional commitment well in excess of non-cancer care providers.Ideally, this commitment involves an extraordinary degree of flexibility, self-awareness, communicative skills, substantial patience (never impatience), and most importantly, a willingness to emotionally connect -- often in a loving and supportive way -- with these people.Much of this type of behavior has to be more than cursory -- beyond tokenism, so to speak -- must always be real, and involves a physician allowing himself/herself to become emotionally vulnerable. This is so because of the huge psychological impact of this disease on the typical patient, who is vulnerable and frightened to the core.

From the patient’s perspective, an “ideal” relationship with their cancer doctor makes the whole experience of diagnosis and treatment, and whatever follows, substantially more tolerable and less frightening.Importantly, a physician’s emotional commitment begets the patient’s trust as well as their ability to find hope.In my opinion, the trust in one’s doctor -- especially in matters pertaining to cancer -- transcends all other emotion-related matters, and this general theme runs throughout the core of my recently published book, The Cancer Experience: the Doctor, the Patient, the Journey.

Notably, trust and hope are inextricably linked, and to understand what I mean by this, hope must be redefined.Too often, we in the oncology community think of hope only in terms of cure or control -- success or failure. In point of fact, hope can be for less dramatic goals -- a prolongation of life that allows for closure -- a mending of important relationships that have run amok, perhaps with loved ones, friends, or with divinity.Hope can be for a good and tranquil death, rather than the indignities of turbulence, painful, and a fitful exodus while alone and connected to machines.

Herein, lies the link between trust and hope.In order to achieve the latter, the patient must have complete and total trust, not just in the integrity of their physician, but also in the doctor’s beneficence.

Put another way, “will my doctor tell me everything truthfully, and will he/she recommend or discourage in a fashion that is in my best interest, just as if I were in his/her family?” Importantly, “will my doctor usher me through the final journey, that is, all the way to death?” We all know that one of the most consistent fears of cancer patients is the fear of abandonment. The emotional presence of their treating doctor is a much-needed part of the patient’s final exit!

Just how we are able to achieve this level of personal connection with our patients seems to me to be an exercise for each of us in self-awareness and personal emotional maturation.

I now realize that I lacked the emotional capacity for this in the early stages of my career. Most of us, perhaps not all, come to realize that being an oncologist is a sober life, with little room for frivolity or casualness -- most of medicine is, but with cancer, whether justified or not the stakes are perceived to be higher, and the patient population -- more emotionally needy than most -- develops a dependency on their oncologist that exceeds the ordinary.

It’s intuitive to me that ideal doctor/patient relationships must start with the lowering of our own protective emotional barriers -- those same barriers that often prevent people from allowing themselves to become attached to others because of fear of emotional pain. Put in the medical context, when a patient fails treatment and the cancer wins, death can be depleting for a physician.It follows that the greater the emotional connection with the patient, the greater the vulnerability of the physician to their own emotional consequences that result from the patient’s suffering and death.My contention for your consideration is that this goes with the job, and we somehow have to step forward and endure.

From the doctor’s perspective, the real emotional rewards of oncology -- the gratification -- the wonderful feeling of having really connected -- are dependent on a willingness to swim in these emotional waters. Cancer cure is great -- it’s what we strive for -- but personal gratification is also about sharing that state with a patient in which we feel their gratitude; and that state of nirvana is only achievable if one allows one’s self to partake of those emotions that many of us sought to avoid before our emotional maturation.

In an attempt to help patients and their families understand why this state of mind is not automatically present in cancer doctors, it is important not to make any excuses for those physicians who fail to find this capability.In saying that there are understandable reasons for this is not meant to justify it, but the lay public will ultimately benefit from understanding their doctor’s emotional composition and perhaps the “distance” that they feel.

Because of the intense preoccupation with education and an almost overwhelming schedule from the beginning of college, some physicians are slow to mature emotionally and in the cancer physician, such a deficiency turns out to be more compromising because the typical cancer patient needs much more than “cancer treatment.”

Thankfully, many physicians grow emotionally, and become able to shed their defenses. It is my belief that out of this come the sublime rewards afforded to the oncology family.